The penalties and bonuses assessed under Medicare's hospital Pay for Performance (P4P) programs focus an unprecedented amount of attention on a limited set of performance metrics; this intense emphasis may create unintended consequences for areas outside the focus of these programs. Medicare will assess about $878 million in penalties against hospitals under the Hospital Readmission Reduction Program (HRRP) and Hospital Acquired Conditions Reduction Program (HACRP) this year, and an additional $1.8 billion will be withheld from inpatient payments covered by the Hospital Value Base Purchasing (HVBP) program to be used later for value- based incentive payments. The size of these incentives, along with the precedent they set for future value- based programs make in-depth study of their impact absolutely critical. We propose to see how introduction of these programs may have affected a range of quality and safety areas, especially areas outside the focus of the programs, using AHRQ's inpatient quality indicators (IQIs) and patient safety indicators (PSIs). Q1: How have Medicare's hospital P4P programs affected metrics outside the programs' focus? Hypothesis #1: Quality and safety metrics for areas outside the focus of Medicare's hospital P4P programs have deteriorated, or improved more slowly, compared to time periods prior to program introduction. Hypothesis #2: Quality metrics not clinically related to focus areas have been most affected. Using interrupted time series, we will examine the impact of P4P introduction on IQIs and PSIs that capture quality and safety for patients that fall outside the program focus. We also propose fuzzy difference-in- differences (f-DID) analysis to compare metrics within and outside the program focus. Q2: Does the magnitude of penalties or bonuses affect how a particular hospital's metrics change in response to P4P? Hospitals with large penalties may divert resources to improve their metrics in focus areas, leaving fewer resources to address quality and safety in other areas. This may be especially acute for financially troubled hospitals. Hypothesis #3: Hospitals facing large penalties will demonstrate greater deterioration/improvement attenuation in metrics outside P4P focus, compared to those with low/no penalties. Q3: How have Medicare's hospital P4P programs affected metrics for non-Medicare patients? Hospitals may find it unethical, impractical or unprofitable to treat Medicare patients differently from other patients. If so, we may observe ?spillover? to other patients. Hypothesis #4: Metrics outside P4P focus have also deteriorated for non-Medicare patients, or improved more slowly, compared to time periods prior to program introduction. Combining 2007-2016 HCUP State Inpatient Databases (SID) from 14 states with publicly reported penalties and bonuses, American Hospital Association (AHA), Medicare hospital, Area Health Resource File (AHRF) and census data to address study questions. Our analyses will identify and quantify potential unintended effects of HACRP, HRRP and HVBP on areas and populations outside the focus of these programs.